The gap between numbers of organ donors and numbers of patients
awaiting organ transplant grows larger every year. Based on Organ
Procurement and Transplantation Network (OPTN) data as of June 30, 2002,
the United Network for Organ Sharing (UNOS) reported that there were
80,076 names on the national patient waiting list for organ transplant.
According to OPTN data as of August 3, 2001, 5,984 cadaveric donors were
recovered and more than 17,000 transplants from cadaveric donors were
performed for the year 2000. Technological advances such as
hemodialysis, cardiac assist devices, and improved pharmaceuticals have
enabled people to live longer lives, but many on the waiting list still
die from eventual organ failure.

One alternative for increasing the pool of potential organs is the
policy of presumed consent. Healthcare providers and ethicists continue
to debate the pros and cons of such a policy change (Caplan, 1983;
Cohen, 1992; Dukeminier & Sanders, 1968; Erin & Harris, 1999;
Moustarah, 1998; Sadler, 1992; Veatch & Pitt, 1995). What are the
lessons learned from countries and states that have implemented forms of
presumed consent legislation? In this article circumstances of presumed
consent are explored and the implications of a policy change for
neuroscience practitioners caring for potential donor patients are
discussed.

Background

The Uniform Anatomical Gift Act (UAGA) of 1968 passed in 1971 in
all 50 states and the District of Columbia. It addressed various issues
related to organ donation. UAGA sought to answer such questions as who
might make legal gifts of one's body or body parts, what are the
rights of next of kin in setting aside a decedent's wishes, what
are the mechanisms for making one's wishes known, and how might
gifts be revoked by a donor while alive (Harris & Alcorn, 2001).

Despite a 1983 Gallup survey indicating a predominant willingness
by the public to donate their organs after death (Cohen, 1992), there
remained a substantial gap between those who stated their willingness
and those who actually signed a donor card (Caplan, 1983). Even fewer
had discussed their wishes with family members, close friends, or
doctors or made note in their wills. Of those who knew about organ
donation, 75% said they would give permission to donate their
child's kidneys if the child was in a fatal accident, but only 25%
said they would give permission to donate their own kidneys after death
(Caplan).

The National Organ Transplant Act (NOTA) of 1984 endeavored to make
donation more efficient and effective (Harris & Alcorn, 2001). It
established OPTN within the U.S. Department of Health and Human Services
(DHHS) as a coordinating body among regional organ procurement
organizations (OPOs). NOTA prohibited the purchase or sale of human
organs.

In the UAGA of 1987, legislation mandated hospitals to establish
request policies to qualify for Medicare reimbursement; healthcare
providers were required to request consent from families of eligible
organ donors. The Joint Commission on Accreditation of Health Care
Organizations will not accredit a hospital unless it has a required
request policy in place. After CPOs and transplant advocacy groups
spearheaded intensive educational programs to increase the public's
knowledge about organ and tissue donation, a more recent survey in 1993
indicated that 75% of Americans were willing to donate an organ after
death (Siminoff, Arnold, Caplan, Virnig, & Seltzer, 1995). Despite
increased public support, however, these policies and programs, which
were designed to address the benefits and impact of organ donation, have
failed to increase the supply of organs for transplantation.

In a chart review of more than 10,000 cases at 23 hospitals,
Siminoff et al. (1995) found that 81% of healthcare professionals
correctly identified potential organ donors and donor families were
approached in 73% of the eligible cases, yet only 47% of the families
agreed to organ donation. The authors recommended educating healthcare
professionals to improve their communication skills with potential donor
families, because talking about donation during a family's acute
grief period was uncomfortable for many healthcare professionals.

DHHS regulations concerning conditions of participation for
hospitals regarding organ, tissue, and eye procurement (DHHS, 1998)
stipulated that only individuals trained in requesting organ and tissue
donation be allowed to make these requests. Representatives of the
private OPOs that are charged with all cadaveric organ and tissue
procurement within their specified catchment area are assumed to have
been trained in the consent process for organ donation.

Wendler and Dickert (2001) conducted a telephone survey of all 61
active OPOs in 1999 about their consent practices for organ procurement.
They found "significant divergence" in practices (p. 332).
When surveyed about their organizational practice in different
scenarios, an equal "number of OPOs (19) follow[ed] the
deceased's wishes as follow[ed] the wishes of the next of kin"
(p. 332). Wendler and Dickert concluded that the dissimilar practices
were attributable primarily to inherent ethical differences. For
instance, one group may believe that following the deceased's
wishes reduces the emotional effect on the family and the other group
believes that it increases the effect on the family.

The current consent process, in which healthcare providers obtain
express consent from a donor's recorded wishes or from family, has
failed to supply the number of cadaveric organs needed to save the lives
of many patients with end-stage organ disease. Is a fundamental change
in public policy called for, and which alternative is the best?

Strategies to Increase the Organ Supply

Since the first successful kidney transplant in 1954, one of the
focal points of the transplant community has been increasing the organ
supply through various procurement methods. The potential reasons for
the current shortage of organs in the United States are (a) failure to
identify potential donors, (b) refusal to donate, either by potential
donors or families, and (c) failure to request donation (Spital &
Erin, 2002). Current procurement proposals, which seek to address these
concerns, include options of express donation, presumed consent through
opting out, presumed consent through conscription, mandated choice,
compensation, and an organ market.

Express Donation

The process currently used in the United States to obtain organs
for transplantation relies on express or voluntary donation or consent.
The principles of informed consent and encouraged voluntarism formed the
basis for the UAGA of 1968 (Sadler & Sadler, 1984). According to
Sadler and Sadler, who consulted in the drafting of UAGA,

The advantage of express donation is that individuals or families
are able to state unequivocally their wishes about organ and tissue
donation. The disadvantage is that this policy has failed to procure
needed organs for transplantation. Although many people agree in
principle with organ donation, they may not take the necessary steps to
complete paperwork or discuss the issue with their family or doctor
(Caplan, 1983).

Presumed Consent

Two versions of presumed consent policies exist: opting out and
conscription. Opting out policies assume that all people consent to be
organ donors upon their death unless they or their families specifically
refuse or "opt out" of donation (Davis, 1999). A discussion of
the logistics and ethics of adopting this option follows in the next
section.

The most inflexible form of presumed consent is the idea of
conscription of cadaveric organs. "All usable organs would be
removed from recently deceased people and made available for
transplantation; consent would be neither required nor requested and,
with the possible exception of people with religious objections,
opting-out would not be possible" (Spital & Erin, 2002, p.
612). Advantages are seen as obtaining cadaveric organs more
efficiently; applying a simpler, less costly process to organ
procurement; removing the discomfort of making requests and time delays
in locating next of kin; and addressing the ethical principle of
distributive justice (Spital & Erin). This proposal is unlikely to
be accepted by the American public because of apparent infringements on
individual autonomy and lack of respect for the wishes of families or
religious beliefs.

Mandated Choice

Mandated choice, also referred to as required or routine response,
would allow people to "have the opportunity to indicate a
willingness or objection to donation ... [and] the option to delegate
the donation decision to his or her next of kin or designated
surrogate" (Presumed Consent Subcommittee, Ethics Committee, UNOS,
1993, p. 9). Using a document that most adults would ordinarily
complete, such as a driver's license application or renewal or an
income tax return, people would be required to consent or object to
donation prior to their death.

Advocates claim that mandated choice respects individual autonomy
and might prove to be a bridging mechanism to presumed consent. They
suggest that the emergence of a societal consensus on transplant
donation may evolve through a policy of mandated choice (Presumed
Consent Subcommittee, Ethics Committee, UNOS, 1993). Successful
implementation would require that an informed, educated public
understand the intent and significance of organ donation (Futterman,
1995).

Organ Donation Compensation

The 1984 NOTA made it illegal to sell any human organ for
transplantation. Most Americans disapprove of payments to donors'
families for organs, but the majority of people favor "some form of
financial or non-financial compensation in an effort to increase the
number of organs for donation" (Garcia, 1997, p. 3257).
Compensation might take the form of preferred status for the donor or a
relative in the event they should need a transplant or reimbursement for
hospital or funeral expenses.

A more economically based approach would be to develop an organ
market or make direct financial payments for donated organs. Opponents
to any form of compensation object because of fears that donors might be
killed or allowed to die earlier than necessary or that the poor might
be exploited (Childress, 1989). However, because public opinion does not
support sales of organs and physicians remain opposed to organ markets,
compensation is unlikely to become public policy.

Harris and Alcorn (2001) proposed consideration of a regulated
posthumous organ market with "direct and indirect financial
encouragement ... structured to avoid abuses, and to reserve altruism as
a central motive" (p. 232). Contracts might have safeguards
prohibiting relatives from selling a decedent's organs without
prior consent, to be based on performance or the actual recovery of fit
organs, not just promises to donate organs, exempting minors from
participation, or offering bonuses for healthier lifestyles.
Distribution of organs would remain under the current OPO structure.

Study of the Options

Economists Barnett and Kaserman (1993) explored six proposed organ
procurement systems in the literature and evaluated them to determine
the best policy. They used criteria based on the "impacts of the
alternative policies on the principal stakeholders": transplant
recipients, potential and actual organ donors and their families,
taxpayers or other payers of transplants, and physicians or other
caregivers (p. 119). Without using ethical considerations, they ranked
each policy "in terms of its overall relative desirability"
(p. 129). Including physicians' preferences, Barnett and Kaserman
found, in terms of societal benefits or yielding the greatest number of
organs for transplantation, that conscription and organ markets ranked
first and second; presumed consent and express donation tied for last.
They determined that mandated choice, organ markets, compensation, and
express donation would be ethically acceptable because these policies
would not violate any of Childress's moral and ethical principles:
respect for persons, beneficence, nonmaleficence, and justice.

Presumed Consent Policy for Organ Procurement

Conceptual Framework

Having identified failure to obtain consent as a key factor in the
organ shortage, the transplant community has exerted efforts on putting
policies in place that will improve the consent rate. As noted in the
previous section, two versions of presumed consent policy, conscription
and opting out, exist. Conscription of all usable organs from cadavers,
without regard to the wishes of the deceased or family members is the
stronger variation. The weaker policy of presumed consent, and the focus
of this article, requires that individuals opt out of organ donation. As
public policy, it

Advocates (Caplan, 1983; Dukeminier & Sanders, 1968; Kennedy et
al., 1998; Moustarah, 1998) claimed that a presumed consent public
policy would increase the number of cadaveric organs available for
transplant. It would make the donation process a routine event when an
adult dies. It would respect individual autonomy. It would decrease the
stress placed on requesters who must approach grief-stricken families
for their consent under current policy. It would diminish the emotional
pressures on bereaved families to make decisions about donation.
Dukeminier and Sanders asserted that the "burden of action"
would shift from healthcare providers "to the dead donor or his
next of kin" (p. 418).

Opponents (Sadler, 1992; Sadler & Sadler, 1984; Veatch &
Pitt, 1995) to the policy of presumed consent argued that it would not
increase the number of available organs. According to U.S. surveys, less
than 40% of the public, and less than 7% in another survey, support a
presumed consent system (Veatch & Pitt). It would remove freedom of
choice from individuals. Establishing a central registry to record
objections would be problematic. It would place a burden on the
individual to register his or her refusal. It would require access to
the system with changes in next of kin through marriage, divorce, and
death, and add a step to the organ procurement process to verify
objections (Sadler & Sadler, 1984). Education would be paramount to
ensure that all individuals understand the shift in policy. It would
require guaranteed legal immunity for healthcare providers who act in
good faith and need to be applied across state lines (Sadler, 1992).

International Policies Based on Presumed Consent

Most European nations, as well as some South American countries,
Israel, and Singapore (Harris & Alcorn, 2001), have implemented
public policy based on presumed consent. To date, however, no
English-speaking nation has adopted a policy of presumed consent
regarding organ procurement (Stuart, Veith, & Cranford, 1981).

The laws of the different countries vary on how organs are
recovered from the deceased who has not expressed a wish during his or
her lifetime (Kennedy et al., 1998). In Norway, organs are removed after
relatives are informed of the intent, regardless of their consent, with
the exception of the nearest relative. The Italians remove organs only
after ensuring the family does not object.

In Austria, organs are removed regardless of the relatives'
attitudes after the physician ascertains there is no refusal in the
patient's medical records. This policy has led to better rates of
kidney procurement than in the United States and most other European
nations, but Austria's rates of procurement for other solid organs
have not improved (Harris & Alcorn, 2001).

In France, after checking medical records, physicians consult with
family members to determine whether the deceased had declared a refusal.
In practice, physicians then inquire about the wishes of the next of
kin. This policy has essentially turned the employment of presumed
consent into a voluntary donation system controlled by the family
(Harris & Alcorn, 2001). The policy has had little effect in meeting
the country's needs for organs.

The Belgian government passed legislation in 1986 based on presumed
consent to procure organs (Roels et al., 1991). Roels et al. reported
there was a significant increase in the number of cadaveric kidneys,
hearts, and livers available for transplant in the 3 years following
enactment of the law. Compared to Austria, another country with presumed
consent policy, and to the Netherlands and ER. Germany, both with
opting-in policies, they found "that only in the two countries with
a presumed consent legislation, [had] multi-organ harvesting increased
substantially" (p. 904).

Belgian citizens who wish to opt out of donation may do so at the
local town hall. Doctors are still encouraged to contact relatives in
all cases, but less than 10% of families object, compared with 20%-30%
in other European countries (First, 2001). In a study of objectors to
donation, Roels, Deschoolmeester, and Vanrenterghem (1997) found that
the cumulative registry of objectors over the initial 8 years of the
presumed consent law comprised 1.75% native Belgians and 3.23%
foreigners (residing for more than 6 months in the country). Objection
rates were highest for minors younger than 14 years, and higher among
children of foreigners than natives, and significantly more females of
all ages than males objected.

In 1997, Brazil passed a presumed consent law despite opposition
from medical organizations, only to repeal the law 1 1/2 years later
(Csillag, 1997, 1998). After passage of the law, surgeons continued to
ask families for consent prior to removing organs. In October 1998, the
law was amended to avoid conflict between the legal mandate and practice
policy to require family permission, essentially negating "presumed
consent." The implementation of a national registry for transplant
recipients failed, and many people feared their organs might be removed
precipitously and rushed to register themselves as objectors (Csillag,
1998).

State Policies Based on Presumed Consent

A number of states have enacted legislation based on the weaker
"opting out" version of presumed consent. State laws differ in
the circumstances in which removal of organs may occur.

Texas, in 1991, was the first state to allow "retrieval of
organs without explicit consent, albeit in limited circumstances"
(Presumed Consent Subcommittee, 1993, p. 4). If a decedent's next
of kin could not be found in a reasonable time, the law allowed removal
of organs. When next of kin were contacted, relatives' wishes were
respected unless the potential donor had indicated a donation preference
in his or her lifetime. If the potential donor was older than 18 years
and had indicated a desire to be an organ donor on the driver's
license, the law supported honoring the donor's wishes without the
consent of any other individual. Since that time, the Texas law has been
changed to require next-of-kin consent even if a clearly documented
advance directive exists (The Lewin Group, 2000).

Legislative proposals followed in Maryland and Pennsylvania in 1993
(Veatch & Pitt, 1995). In Maryland, the bill would have allowed
presumed consent for cases in which a decedent had not opted out. It was
defeated, as was a previous version of the law. In Pennsylvania, the
proposed act would permit removal of organs and tissues unless the
potential donor had refused.

According to the Presumed Consent Subcommittee (1993), the above
proposals had similar characteristics using the language of presumed
consent. For example, unless the potential donor had expressed an
objection to donation, he or she was presumed to have wanted to donate.
Next-of-kin objection to donation overrides the potential donor's
presumed consent, if said donor had not expressed an objection. The
potential donor's recorded preference for donation prevails over
the objections of next of kin. Reasonable efforts must be made to
contact next of kin.

Reportedly, since then, 10 states have enacted legislation that
recognizes a signed driver's license as an advance directive and
provides protection "to OPOs, hospitals, and tissue and eye banks
when carrying out individuals' advance directives without further
consent" (The Lewin Group, 2000). Pennsylvania also has initiated a
pilot program that offers $300 toward funeral expenses as an incentive
to donate (First, 2001). Will efforts like these lead individuals from
making voluntary, humanitarian decisions or donations to making forced,
mercenary decisions? Or does presumed consent imply a belief in
community generosity?

Ethical Considerations

Scientists and ethicists debate the moral and ethical correctness
of the presumed consent concept. Childress (1989) wrote a definitive
piece analyzing, from an ethical perspective, various policies on organ
procurement "in light of moral principles already embedded in U.S.
institutions, laws, policies, and practices" (p. 87). These
"embedded moral principles are respect for persons, including their
autonomous choices and actions; beneficence, ... nonmaleficence, ... and
justice" (p. 88). In addition, there are different views about
whether human body parts are property and who has rights to use,
possess, dispose, or change possession of this property.

Childress (1989) stated that to find presumed consent ethically
acceptable one must view the individual's or family's wishes
as "tacit consent," silently or passively expressed "by
omissions or by failures to indicate or signify dissent" (p. 96).
He argued that this silence may only mean one lacks an understanding of
the process or does not know how to register a dissent. In terms of
ethical preferability, presumed consent relies on passive altruism, but
does not rule out active altruism.

Veatch and Pitt (1995) spoke to the core relationship of the
individual to society regarding presumed consent. Specifically, "in
liberal Western society certain rights are attributed to the individual
... medical treatment is acceptable only with the consent of the
individual or the individual's appropriate surrogate" (p.
1890). If one sees organ procurement as giving, as evidenced by words
like "donor," presumed consent can be valid. If one sees organ
procurement as taking, society will be asserting its rights over the
individual without his or her permission.

Erin and Harris (1999) argued for presumed consent because they
"believe it is the right thing to do because ... it is in the best
interests of those patients in need of an organ, and that not to remove
these organs would be to harm those patients" (p. 365). They agreed
that the presumption of consent directly contradicts the principle of
respect for individual autonomy. However, "if we are to presume
anything, we should presume that people would wish to do the morally
right thing" that is, to make cadaver organs "available for
life-saving or life-enhancing use" (p. 366).

Other advocates (Caplan, 1983; Cohen, 1992; Kennedy et al., 1998;
Moustarah, 1998) followed similar lines of reasoning. Presumed consent
policies will uphold the principle of beneficence; saving lives is good.
Cohen (1992) wrote that consent or refusal may be required to opt in or
opt out of donation, but a presumption must be made with the burden
falling "upon those for whom the presumption made is
incorrect" (p. 2172).

Although there is no consensus that presumed consent policies are
ethically or morally correct or even more effective in procuring organs,
all parties agreed that certain measures must be in place if a
transition is made from a public policy of expressed to presumed consent
for organ procurement.

Effect of Enacting a Public Policy of Presumed Consent

Changing national policy from opting in to opting out of organ
donation would require societal changes in attitude of both healthcare
providers and the public. Technically, policy change would require the
formation of a central registry, an efficient means for individuals to
register their objections, and a consistent, reliable method of
accessing, entering, updating, and respecting this data (Futterman,
1995). It would necessitate a massive public education program about
organ procurement and the new program requirements.

Opponents of presumed consent argue that there is no mechanism in
place to consolidate and safeguard objections to donation and that this
could be a cumbersome nightmare to achieve. Proponents of presumed
consent refute this stance. The United States has large databanks in
place for various other nationally required programs such as income tax,
Social Security, and the selective service system. Surely with
technological capabilities and assistance from countries with effective
registry programs in place, these technical difficulties could be
overcome (Moustarah, 1998).

Many states currently do not have databases of individuals who have
indicated their willingness to be donors. Of the states that do maintain
registries, most of these programs involve driver's license/motor
vehicle departments and some state health departments, but
round-the-clock access is rare (The Lewin Group, 2000).

State legislative efforts on organ procurement vary. Is a national
consensus possible? Singapore enacted presumed consent policy for kidney
procurement in 1987. Their plan of action was twofold, using presumed
and voluntary consent. Muslims were "automatically considered
objectors ... on religious grounds" under the presumed consent
policy but, "they could voluntarily pledge" by signing a donor
card (Teo, 1991, p. 10). Despite ethical questions, the government made
"very laudable efforts to make its presumed consent policy
ethically defensible" by supporting public knowledge prior to
passage of the law (p. 13). They conducted extensive media programs, had
well-publicized public and parliamentary discussions, and sponsored
public awareness programs and hearings.

Perhaps the greatest hurdle to enacting a presumed consent policy
in the United States is the ethical debate. Presumed consent belies the
American value of respect for individualism. Diversity in age, culture,
education, and economics, and individual responses to bereavement must
be considered is making such a dramatic change in organ procurement
policy (Futterman, 1995). How will healthcare providers be affected if a
presumed consent policy is established?

Implications for Healthcare Professionals

As any bedside nurse, advanced practice nurse, physician, or
therapist recognizes, knowledge of a particular healthcare issue and
personal insight into one's own knowledge, beliefs, and values
about that issue are key to communicating effectively with patients and
families. When presumed consent policies are debated in the healthcare
or public venues, practitioners have the opportunity to explore their
own values and beliefs and make decisions about how to interact with
families and patients who may be potential donors or recipients of
organs. If a policy transition were to occur, providers would need
extensive self-education before educating the public.

It is essential that professionals in the neuroscience, trauma, or
critical care domains understand the concepts of brain death and the
procedure for procurement of organs for transplantation. If public
education campaigns have been successful, in the event of a policy
change, families should come to expect the routine recovery of any
usable organs from their deceased family member. However, support for
the grieving family should be available as well as resources to explain
the procurement process if any questions arise.

For professionals in family or primary care, it would be important
to understand the changes in process and laws on registering objections
to organ donation. Patients may ask questions about the technicalities,
their medical care, or the morality of presumed consent. Practitioners
may need to learn more about advance directives and become more
comfortable addressing the issues of death and dying.

For professionals in organ transplantation, the implementation of a
presumed consent policy may improve their patients' chances of
receiving a life-enhancing or lifesaving transplant. Practitioners may
encounter these individuals when they are discovering they need a
transplant, during the evaluation and selection as a transplant
candidate, during the waiting period, or after the transplant. Until an
increase in available organs becomes more apparent, practitioners need
to continue to support the physical and emotional needs of these
patients.

Summary

Policies of presumed consent to procure organs for transplantation
have stimulated discussion of success/failure in increasing organ
availability, technical pitfalls, and ethical dilemmas. The presumption
of consent has made inroads in public policy internationally and
influenced some state policies. A policy of presumed consent remains
unlikely in the face of American attitudes of freedom of choice and
respect for individual autonomy but healthcare providers need to be
aware of potential policy changes and how these changes may affect their
practices.

Presumed Consent Subcommittee, Ethics Committee, UNOS. (1993,
June). An evaluation of the ethics of presumed consent and a proposal
based on required response. Richmond, VA: Author.

Roels, L., Deschoolmeester, G., & Vanrenterghem, Y. (1997). A
profile of people objecting to organ donation in a country with presumed
consent law: Data from the Belgian national registry. Transplantation
Proceedings, 29, 1473-1475.

Roels, L., Vanrenterghem, Y., Waer, M., Christiaens, M., Gruwez,
J., & Michielsen, P. (1991). Three years of experience with a
'presumed consent' legislation in Belgium: Its impact on
multi-organ donation in comparison with other European countries.
Transplantation Proceedings, 23, 903-904.

Stuart, F., Veith, E, & Cranford, R. (1981). Brain death laws
and patterns of consent to remove organs for transplantation from
cadavers in the United States and 28 different countries.
Transplantation, 31, 238-244.

The Lewin Group, Inc., for the Office of the Assistant Secretary
for Planning and Evaluation. (2000, January 4). Analysis of state
actions regarding donor registries. Retrieved April 5, 2002, from
http://aspe.hhs.gov/health/orgdonor/stat
e%20organ%20donor%20registries.htm

Wendler, D., & Dickert, N. (2001). The consent process for
cadaveric organ procurement: How does it work? How can it be improved?
Journal of the American Medical Association, 285, 329-333.

Questions or comments about this article may be directed to: Carol
J. Roberts, MSN RN CCRN, by phone at 804/828-9244 or by e-mail at
cjrobert@hsc.vcu.edu. She is a clinical nurse IV in the neuroscience
intensive care unit at VCU Health System, MCV Hospitals and Physicians,
Richmond, VA.

The law is doing well what it
was intended to do: providing
a clear mechanism for individuals
and next-of-kin to consent
to organ and tissue donation
for humanitarian purposes. It
was designed to strike a socially
acceptable balance that facilitates
organ donation and
procurement without infringing
upon other deeply held
values and rights. (p. 6)

would offer every adult the
opportunity to express and
have recorded by publicly
accountable authorities his or
her refusal to be a donor of
solid organs and tissues. A
clinically and legally indicated
candidate for cadaveric
organ and tissue recovery is
presumed to have consented
to organ and tissue recovery if
he or she had not registered a
refutal [sic]. (Presumed Consent
Subcommittee, 1993, p.1)